What are the pros and cons of Medicare HMOs? Can my parents keep their current doctor?

Dr. John Connolly

Many primary-care physicians provide services to eligible members of managed-care plans (including HMOs) as well as traditional fee-for-service care to other patients. In other words, if you enroll in a Medicare HMO you might be able to choose your current physician as your "gatekeeper," maintaining the good doctor/patient relationship you seem to have.

Still, getting the doctor you want should be only one criterion in deciding whether to join a Medicare HMO. First, the pluses: 

• Less paperwork. Because the HMO combines the health-care and insurance sides of the care you receive, there is less back-and-forth hassle over bills from an insurer.
• Additional benefits. Besides the Medicare Part A (hospital and related care) and Part B (doctors, outpatient care and more) services, without membership in a Medicare HMO you will have to sign up separately with an insurance carrier to receive any supplemental coverage you may need. Called Medigap, some such services are included with HMO membership for less cost--though it helps to shop around for the services you think you may need.
• Preventive care. The cold side of HMOs is that they make the most money when patients never get sick. The positive side of this is they are inherently stronger than fee-for-service plans at promoting ways to avert health problems through diet, exercise, and other lifestyle options.
• Predictable costs. Other than a small copayment, which you pay when you receive HMO services, plus the usual Medicare deductibles, HMO costs are fixed. Medicare pays the membership premium. Keep in mind, though, that you pay extra if you decide to see another doctor outside the HMO's network or without following the usual referral procedure.

Yet it isn't for nothing that HMOs have earned plenty of criticism through the years. Here are a few of the reasons why people say thanks but no thanks to HMOs, keeping their fee-for-service plans as long as they can: 

• Restricted services. Of course, you (sometimes even your attorney) should read the fine print on any contract you sign. But if you or your wife have any long-term health problems, you will need to be sure--before you join an HMO--that coverage for services related to that problem are adequately covered and without an unmanageable time limit. Kidney failure, for instance, raises a red flag for HMO plans. Be sure also that the HMO includes some provision for reimbursing you for emergency care you receive should you be unable to contact your primary-care doctor.
• Restricted providers. Keep in mind that any network of doctors is going to be a subset, a smaller overall group, of all the doctors available in your locality. This means fewer choices, which in your case means fewer specialists if you need someone beyond your primary-care physician. Depending on the terms of your plan, you can use a specialist outside the network but the HMO will not fully pay--or won't at all. Your primary-care physician will also need to refer you to another physician.
• Geographical restrictions. If you and your wife travel or have two residences, reimbursement for medical care you receive outside the HMO's regional area may be restricted in some way. At the very least, you will need the HMO's preapproval before obtaining services while you're away.
• Special disenrollment periods. Should you join an HMO and eventually decide to return to your current arrangement, it can take up to 30 days to disenroll from a managed-care plan. Disenrollment is performed through either the HMO or a Social Security Office, and you must submit your intentions in writing. One exception here is if you switch from one HMO to another; the new HMO will disenroll you from the old.

You and your wife are in the unique position to learn all you can about Medicare's various options before coverage begins.

Dr. John Connolly is President & CEO of Castle Connolly Medical Ltd., America's "trusted" source for identifying top doctors. He has an extensive background in management and healthcare. For more than a decade, he was President of New York Medical College where he successfully revitalized the school while insuring its financial security. Dr. Connolly is extensively involved in healthcare activities including serving as a director of the New York Business Group on Health, as founder, a director and past chair of the American Lyme Disease Foundation, as a member of the Presidents Advisory Council of the United Hospital Fund of New York, and as a Fellow of the New York Academy of Medicine. He has also served on the boards of two hospitals and as chairman of the board of one, and is currently Chairman of Professional Examination Service, Inc. He also is a frequent guest on regional and national TV and radio shows, including 20/20, CNN and Good Morning America.